As a root cause analysis expert and former US Navy Officer who was qualified as a Surface Warfare Officer (SWO) and was qualified to stand underway steaming Officer of the Deck watches, I’ve had many friends ask me what was the root cause of the collision of the USS Fitzgerald.

Of course, the answer is that all the facts aren’t yet in. But that never keeps us from speculation…

Also, let’s note that the reason for good root cause analysis is to prevent fatalities and injuries by solving the problems discovered in an accident to keep a similar repeat accident from happening in the future.

Mia Culpa: It’s been a long time since I stood a bridge watch. I’m not familiar with the current state of naval readiness and training. However, my general opinion is that you should never turn in front of a containership. They are big. Even at night you can see them (commercial ships are often lit up). They are obvious on even a simple radar. So what could have gone wrong?

1. It was the middle of the night. I would bet that one thing that has not changed since I was in the Navy is FATIGUE. It would be interesting to see the Oficer of the Deck’s and the Conning Officer’s (if there was one) sleep schedule for the previous seven days. Fatigue was rampant when I was at sea in the navy. “Stupid” mistakes are often made by fatigued sailors. And who is to blame for the fatigue? It is built into the system. It is almost invisible. It is so rampant that no one even asks about it. You are suppose to be able to do your job with no sleep. Of course, this doesn’t work.

2. Where was the CO? I heard that the ship was in a shipping lane. Even though it was the middle of the night, I thought … where was the Commanding Officer? Our standing orders (rules for the Officer of the Deck) had us wake the CO if a contact (other ship) was getting close. If we had any doubt, we were to get him to the bridge (usually his sea cabin was only a couple of steps from the bridge). And the CO’s on the ships I was on were ALWAYS on the bridge when we were in a shipping lane. Why? Because in shipping lanes you are constantly having nearby contacts. Sometimes the CO even slept in their bridge chair, if nothing was going on, just so they would be handy if something happened. Commander Benson (the CO) had only been in his job for a month. He had previously been the Executive Officer. Did this have any impact on his relationship with bridge watchstanders?

3. Where was the CIC watch team? On a Navy ship you have support. Besides the bridge watch team, you are supported by the Combat Information Center. They constantly monitor the radars for contacts (other ships or aircraft) and they should contact the Officer of the Deck if they see any problems. If the OOD doesn’t respond … they can contact the Commanding Officer (this would be rare – I never saw it done). Why didn’t they intervene?

4. Chicken of the Sea. Navy ships are notorious for staying away from other ships. Many Captains of commercial shipping referred to US Navy ships as “chickens of the sea” because they steered clear of any other traffic. Why was the Fitzgerald so close to commercial shipping?

5. Experience. One thing I always wonder about is the experience of the crew and especially the officers on a US Navy ship. Typically, junior officers stand Officer of the Deck watches at sea. They have from a two to three year tour of duty and standing bridge watches is one of many things they do. Often, they don’t have extensive experience as an Officer of the Deck. How much experience did this watch team have? Once again, the experience of the team is NOT the team’s fault. It is a product of the system to train naval officers. Did it play a factor?

6. Two crews. The US Navy is trying out a new way of manning ships with two crews. One crew is off while the other goes to sea. This keeps the ship on station longer than a crew could stand to be deployed. But the crew is less familiar with the ship as they are only on it about 1/2 the time. I read some articles about this and couldn’t tell if the USS Fitzgerald was in this program or not (the program is for forward deployed ships like the Fitzgerald). Was this another factor?

These six factors are some of the many factors that investigators should be looking into. Of course, with a TapRooT® investigation, we would start with a detailed SnapCharT® of what happened BEFORE we would collect facts about why the Causal Factors happened. Unfortunately, the US Navy doesn’t do TapRooT® investigations. Let’s hope this investigation gets beyond blame to find the real root causes of this fatal collision at sea.

I think it will be very interesting to see the investigation. With the experience the Navy has, there are rarely any new lessons to learn – only unlearned ones. The factors you list could certainly come into play, but there are many backups to mitigate these issues. I wonder if complacency is an additional consideration. The ship was stationed in Yokosuka and probably operated in the Tokoyo Wan area frequently. This could lead to complacency and not following their established processes.

I’m not so sure if there are no lessons to learn. Collisions at sea aren’t that rare. The Navy has had many over the decades and it seems as if there are always firings … but seldom any systemic change.

As for complacency going into your home port … You don’t go in and out all that often. The Navy isn’t like cruise ships. They go out and stay out for quite a while. But they may be fatigued when coming back to port after an exercise or deployment.

I was offshore out of LA Harbor running west from Land’s end of Catalina and so about 24-26 NM out with 6 souls aboard. Stiff breeze and 3 foot seas so had the rail buried on a reach and speed at hull speed max of 6 kts. I was running a radar reflector that makes my sailboat look like a small freighter. About 2 NM ahead an Aegis Man O’War came out the fog northbound 90 degrees to my bearing and it was a fast mover. How did we get that close? I fly the National Ensign high up from the Leech and so the great ship melted back into the fog bank although I had time to follow tradition and bear off on a tack parallel before she faded back into the fog. No sane person stays on a direct bearing to a Man O’War. Maybe crew saw me a background to island and my blip separated from the island late and startled them when it had movement. Maybe it was like to freighter collision off NY Harbor in the early 1950’s when the crew misread the change of scale on the radar. Maybe since I was out of the fairlane I was completely unexpected.

I’ve seen this question a few times now. Assuming (…) non of the respondents were directly involved, there are only a few facts: International waters, war ship, commercial vessel, collision, fatalities, injuries and damage (structural, financial and reputation). Asking this question in this stage is asking for assumptions. I don’t like it. Let’s await the official reports, scrutinise them and discuss based on facts.

None of the reasons mentioned in your article have a substantial bearing on the accident. These factors are relevant but not something that OOWs can’t handle on a normal day. Regarding the experience of the OOW, no Commanding Officer will let an OOW keep watch at night unless he is quite confident about his ability to navigate safely.

The immediate cause could be very ‘silly’ but it could be classified under ‘ loss of situational awareness’. The root cause is ‘poor safety culture’. How well does an OOW control his team when the rest of the crew and the CO are asleep? Some middlewatch OOWs are tough as nails while others are more ‘humane’, but either way it is important for an OOW to maintain the focus of his team. An OOW’s attention can be diverted by any of a large number of distractions on the bridge. One of the abilities that an OOW must develop is to prioritise his mental processing of alarms and reports. On the PPI full of radar contacts, which one is the most critical? It is a difficult task, but not impossible, but one where the OOW could fail if he allows his attention to be diverted.
Once again, the root cause will only be revealed once the investigation reports its findings.

Those who criticize the training of the US Navy, ought to imagine the horror of the situation when the impact caused such a disabling damage to the warship. No damage control training exercise ever could have ever set up such a scene. It takes some incredible ability to wake up from sleep, orient yourself in the dark, jump into action and succeed in saving the ship. The loss of 7 lives was terrible, but it could have been much worse.

Let’s also consider the time of day, or morning. Just about the same time ‘ish as the ever popular mid-rats. Were sailors off the bridge or away from their stations to stand in long lines for left-over lunch and dinner meal rations? Any sailor who has ever worked the night shift or stood late night watches know you get three meals a day in the galley: breakfast, lunch and dinner. Mid-rats were never a meal and from experience, hardly worth eating or standing in a long line for.

Considering the damage is in the same place on the ship as the USS Porter suffered in a 2012 collision with the tanker MV Otowasan, one could consider a deficiency in implementing any corrective actions from previous collisions.

BZ From a retired 23y USN/USNR Mustang (LT) and veteran. Now at 76y (age) and morphed into Safety & Forensics (ASSE Fellow; ACFEI Fellow.) Well said and on target lacking hard facts at this point. My speculations mirror yours but you put it well having “STOOD” the watch personally. Mine was more Air and land, especially in NAM. Best regards from the eternal family of shipmates.

Hey Shipmate!
Mark, regarding #6, the Fitz is NOT dual crewed. The only dual crewed ships right now are (is) the LCS out of Singapore.
Most of the Burke class DDG’s do not have Sea Cabins but the CO’s cabin is very close to the bridge and CIC.
You and I stood a bunch of watches together and I’m glad that we never had something like this happen.

Those were many of my thoughts. I have a couple of others. Both ships should have been equipped with collision warning alarms. One or both ships must have thought that the other would take evasive action. The Fitzgerald may have a collision avoidance system as well. Tragic accident but it could be that both crews are at fault.

Jumping onto human error from the get-go? What about other possibilities? Rudder failure (on either ship), container ship maneuvers either intentional or not? Haven’t seen any evidence yet other than a photo and the reports of the fatalities. We do not know what maneuvering took place to my knowledge, anyway.

Way too soon to speculate, especially about crew performance,imho. Who is to say the crew didn’t perform heroically?

There is a lot of system analysis that will be done with this incident. I was on a Destroyer Escort home ported in Yokosuka. Now that I think of it I was considered an “old salt” at two years of sea duty. I felt that I was well trained and an old salt at that too. Anywhere else I would have been considered new to the job and still learning….

One other point… We NEVER pulled into port at night because we were always “bone tired” since this is a very busy place.

Undeniably there had to be a big breakdown in the team that was on watch. Don’t Agree with the dual crew being an issue. Ballistic missile submarines have been dual crew since inception in the 1960s. Through rigorous offcrew training in realistic trainers you return to the boat after 105 days ashore ready to go to sea.

Thanks for your comment. If there was dual crewing, during the investigation you would need to check if the surface ship crew was getting realistic training to improve performance while ashore. Just guessing but I bet they spend more on a Trident crews training than on the training of a DDG crew.

For all those who say “wait for the report from the Navy”, be aware that when this becomes available from the Navy, through a freedom of information request, it will probably be heavily redacted and won’t answer many questions that you would need answered for a good root cause analysis. How do I know this? Just look at past reports from US Navy collisions.

All aircraft will be required to transmit information including their location and heading to satellites by a system called ADDS. The surveillance is so rapid that airline traffic can be separated by one third the distance now used. All types of aircraft using a large part of the airspace will be required to transmit ADDS. Perhaps a system of this nature could reduce sea collisions. Perhaps failure of using up to date technology is a root cause.